By Terri Lewis, PhD.
Jeff Sessions has decided that he has the answer to the opioid crisis. His solution: Take two Bufferin and smoke fewer joints. “I am operating on the assumption that this country prescribes too many opioids,” Sessions said Wednesday as he touted the Trump administration’s efforts to combat drug abuse and trafficking. “People need to take some aspirin sometimes and tough it out a little.”
Before I absolutely ‘go off’ on this advice and the conflations emanating from our USDOJ, let’s review the messaging coming out of Attorney General Jeff Sessions pronouncements.
- Everything old is new again. “Just say NO” didn’t work the first time so let’s dust it off and repurpose it. It requires nothing from government, assigns all risks to the population, and creates a mechanism for conducting stepped up enforcement activities.
- Drugs are bad. The opioid epidemic is a personal failing by many Americans who cannot say no to drugs. “Good people don’t smoke marijuana,” and “marijuana is a gateway to the use of other drugs.”
- Doctors prescribe too many opiates. “We think doctors are just prescribing too many,” citing that “2017 saw a seven percent decline in opioid prescriptions, and my goal in 2018 is to see a further decline.”
- Patients lack will power and should suffer through pain to prevent addiction. The Sessions solution? More Bufferin, less marijuana, fewer prescriptions. “Sometimes you just need to take two Bufferin or something and go to bed.” According to Sessions, “Opioids have become so addictive that 80% of heroin addictions begin with prescriptions.”
It is frankly stunning that the USDOJ is led by an individual who is so woefully uninformed, blinded by his own willful ignorance, who surrounds himself with ‘experts’ who are equally as blinded to scientific practices, and who denies evidence derived from population analytics. Moreover, it is even more stunning that we as a public put up with this nonsense and aren’t rolling up to the doors of the Drug Enforcement Administration with pitchforks and torches. Let’s examine what AG Session has failed to learn.
- On June 24, 1982, President Ronald Reagan issued one of the most devastating executive orders of the 20th century when he pronounced, “We must mobilize all our forces to stop the flow of drugs into this country” and to “brand drugs such as marijuana exactly for what they are—dangerous,” he said, announcing his own War on Drugs. While eager to connect Trump’s tenure to the Reagan legacy, in point of fact, “this War on Drugs” has been a miserable failure from its’ inception as it was rooted in racism, and targeted the control of black urban neighborhoods in an era of agitation for civil rights. While hooking the Trump initiatives to Nancy Reagan’s baby may excite the Trump base, the building evidence illustrates that the restriction of prescriptions has virtually no impact on reducing the presence of illicit drugs that are leading to the untimely deaths of Americans. The rate of addiction per 100,000 is roughly the same today as it was during the Reagan administration. By the year 2000, the use of drugs remained steady but incarceration of minorities, particularly black Americans increased condemning an entire generation. AG Session would have us return to these good old days under the guise of law enforcement coupled with treatment as he makes good on his political promises to private prisons to keep their beds filled through increased law enforcement for offenses that would be better served through community based and supported treatment.
- Cannabis is emerging as a reasonable and safe solution for some where precautions and user education are supported. In 2017, the National Institute on Drug Abuse (NIDA) noted that the passage of marijuana laws has lowered rates of prescription opioids in legalized states and that the majority of people who use marijuana do not go on to use other, “harder” substances. In 2015, the Journal of the American Medical Association published a meta-analysis that suggested moderate levels of evidence suggest that cannabis can be a helpful tool to combat chronic pain and spasticity. Stephen Dahmer, MD, in an article for Pain News Network (February 7, 2018) suggests that the evidence for the use of medical cannabis to treat chronic pain is strong and growing exponentially. In December 2017, HelloMD published findings that demonstrated 81% percent of patients prefer marijuana over opiates, while 97% said cannabis has helped them to decrease their reliance on opiates. Good people do use medical marijuana as evidenced by 12 year old Alexis Bortell is now suing AG Sessions for the right to apply this material to her regimen of care for epilepsy and to travel freely while using this as a medication.
- Kratom, recently declared by FDA to have properties akin to opioids, is also in the gunsights of Jeff Sessions DEA for rescheduling as a schedule 1 drug for which there is no evidence of medical use. This week, nine scientists from the fields of chemistry, pharmacy, and behavioral science, who study the mitragynine and 7- hydroxymitagynine, compounds found in this plant issued a letter stating that the current body of credible research on the actual effects of kratom demonstrates that it is not dangerously addictive, nor is it similar to “narcotics like opioids” with respect to “addiction” and “death” as stated by the FDA in its November 14th Kratom Advisory. Dr. Jeff Fudin, further elucidated the open questions involving the pharmacologic components of Kratom and its effect on the human body in a widely shared blog posting found at this link: http://paindr.com/kratom-save-em-bait-em-or-crate-em/. Meanwhile, the 44 deaths (polypharmacy, suicides) that Dr. Scott Gottlieb used to raise alarm bells about the dangerous use or abuse of this plant material are thoroughly described by Nick Wing who requested the details of these deaths through a FOIA and who has shared the complexities of each here on his twitter feed @nickpwing and through his HuffPost piece located at https://www.huffingtonpost.com/entry/kratom-deaths-fda_us_5a7a3549e4b07af4e81eda8b. Clearly, these deaths are associated with multiple complexities that we can recognize as associated with a broad range of risky behaviors and compromised mental health. What we can say about Kratom in these 44 instances is that ‘it’s just not that simple.’
- All drugs have risks. That is the purpose of assessing the risk of harm versus the potential benefits use of any drug might bring to the user. Alcohol routinely kills more people than opiates, not to mention the number of serious injuries caused by drunk drivers that do not result in death but do cause lifetime injuries to themselves or others that result disability and the need for long term pain management. Similar trends are seen in mortality associated with smoking deaths as illustrated at this link- http://www.nejm.org/doi/pdf/10.1056/NEJMsa1211127. Risk benefit analysis for alcohol and cigarettes have balanced the risk of harms against the financial gain to local tax revenue streams, and the personal enjoyments of the population to far greater negative effect than that associated with prescription opiates.
- The prescribing of opiates has significantly trended downward since 2011 across all systems while the use of illicit street drugs – particularly heroin, carfentanyl, and heroin laced with have exponentially increased creating chaos in our communities. Restricting the distribution of opiates for legitimate medical purposes has created a climate of fear among prescribing physicians and the patients they serve whose complex illnesses can be reasonably and positively affected by access to legally prescribed opiate medications. Moreover, restricting the issuance of opiates is having the effect of influencing deaths from polypharmacy and medication roulette as physicians and patients search for alternatives to opiates that are increasingly prescribed off label without clinical trials. This increases rather than decreases patient vulnerabilities. Suicides across our systems of health care are increasing and patients experiencing involuntary discontinuance and subsequent destabilization now openly speak of their plan for suicide by various means. In the VA system alone, opiate prescribing has reduced by 47% even as suicides (but not overdoses) have increased.
- Patient protections are reducing as torte reform strips the rights of patients who experience nearly 400,000 iatrogenic injuries annually through encounters with our medical system. Many of these events yield catastrophic lifetime injuries for which there will be coping required, without cure. While hospitals, insurers, and physicians are shielded from responsibility, these patients are vulnerable to reinjury from a system designed to protect doctors from their actions without affording protection to patients. Those who survive these processes are not weak of mind or heart – they are amazing people who are motivated to continue to work for their families, regain their familial roles and responsibilities, and reassert their community obligations. After every other method has failed, it is the palliation afforded through medications such as opiates that help them to continue to assert their participation in society. AG Sessions is dead wrong when he describes this population of resilient users as “weak-willed.” These are in fact, people who have chosen to persist in the face of incredible and long odds at great expense to themselves, their families, and their communities.
I do not know where AG Sessions obtained his fake doctor degree or how it is that he justifies in his own mind that he has the right to make pronouncements about the health and safety of the sickest among us, the medications that they rely on to cope with their days, or the moral and spiritual stock of Americans. This man is using the weapons of his office to impose his ill-informed beliefs upon the sickest of Americans through the use of diversion strike teams, the weaponization of personal medical data, warrantless searches, and the destabilization of physician and pharmacy practices across the nation. This will do little or nothing to address the problem of illegal trade in street drugs, a fact for which there is already clear evidence. It will cause harm to the health care system and to the patients who are served (or not) in their communities. Attacking the problems of stigma begins by educating policy makers in collaboration with members of the community and the address of social structures that prop up unhealthy and risky behaviors.
The decision to seek care through the method that works best for you and your family, within a safe physician and patient prescribing relationship and the resources that are available to you is not a moral judgment to be regulated. I challenge AG Sessions to check his biases, open his brain to scientific applications, and to seek wiser counsel than he is getting from the yes men and women he has surrounded himself with. I also challenge members of Congress, state legislatures, and community leaders to stop drinking the poison that is being spewed by political action groups. The pressure to ‘do something, anything’ is pronounced and supported by campaign contributions, special interest groups, and the compelling stories of those who have lost loved ones to the opiate wars. But we must remain clear headed as we work to identify the community causes of this problem and the solutions that will move us forward. At the end of the day, the problem of drug utilization and regulation is a complex problem with many interactive features rooted in personal characteristics, political ideologies, and community resources and values.
It’s bigger than take two Bufferin and go to bed. We really can do better than this. We must do better than this. Let’s try.
Correspondence to Kellyanne Conway and Robert Patterson Acting Administrator for the Drug Enforcement Administration, February 8, 2018. Retrieved from https://docs.wixstatic.com/ugd/9ba5da_086cf409644547d9b4df864f707e0d92.pdf
Thun, M.J., Carter, B.D., Feskanich, D., Freedman, N.D. Prentice, R., Lopez, A.D. Hartge, P. & Susan M. Gapstur, S.M. (2013). 50-Year Trends in Smoking-Related Mortality in the United States. New England Journal of Medicine http://www.nejm.org/doi/pdf/10.1056/NEJMsa1211127
Dahmer, S. (2018, February 7). Cannabis Is Compassionate, Not a Conundrum. Pain News Network. Retrieved from https://www.painmedicinenews.com/Commentary/Article/02-18/When-Used-Correctly-Medical-Cannabis-Is-Compassionate-Not-a-Conundrum/46887?sub=3039A8CB8B7D671EA622F79177F1B11FA4193EF8199883FBF1EE18C47A775A&enl=true
Boodman, E. (2018, 02-08). FDA calls kratom an ‘opioid’ and warns against using the supplement. State News online. Retrieved from https://www.statnews.com/2018/02/06/kratom-opioid-fda/
Slatery, D. (2018, 02-09). Patients should suffer through pain to prevent addiction, The Day: Nation/World News online. Retrieved from http://www.theday.com/article/20180208/NWS13/180209420/
Marijuana. NIDA.gov, (2017). Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-gateway-drug
Wing, N.P. (2018, 02-08). FDA Releases Kratom Death Data, Undermines Its Own Claims About Drug’s Deadly Harms. Huffington Post online Retrieved from https://www.huffingtonpost.com/entry/kratom-deaths-fda_us_5a7a3549e4b07af4e81eda8b
Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015;313(24):2456–2473. doi:10.1001/jama.2015.6358
Dr. Terri Lewis is a rehabilitation educator, clinician and researcher who specializes in chronic pain and is a frequent contributor to the National Pain Report.